Healthcare Provider Details

I. General information

NPI: 1316294911
Provider Name (Legal Business Name): CORA CARISSA MCREYNOLDS MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CARISSA C MCREYNOLDS LCSW

II. Dates (important events)

Enumeration Date: 08/14/2012
Last Update Date: 11/09/2022
Certification Date: 11/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6400 UPTOWN BLVD NE
ALBUQUERQUE NM
87110-4202
US

IV. Provider business mailing address

6409 BELLINI LN NW
ALBUQUERQUE NM
87114
US

V. Phone/Fax

Practice location:
  • Phone: 505-670-0335
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberC-09929
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberX-07919
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: